A System of Care for A System of Care for Substance Use as a Chronic Substance Use as a Chronic Health Problem Health Problem Rachel Gonzales Ph.D, Professor Rachel Gonzales Ph.D, Professor Semel Institute for Neuroscience and Human Behavior Semel Institute for Neuroscience and Human Behavior David Geffen School of Medicine David Geffen School of Medicine University of California at Los Angeles University of California at Los Angeles www.uclaisap.org [email protected]Supported by: National Institute on Drug Abuse (NIDA) Pacific Southwest Technology Transfer Center (SAMHSA) California Alcohol and Drug Programs (ADP)
Transcript
A System of Care for Substance A System of Care for Substance
Use as a Chronic Health ProblemUse as a Chronic Health Problem
Rachel Gonzales Ph.D, ProfessorRachel Gonzales Ph.D, ProfessorSemel Institute for Neuroscience and Human BehaviorSemel Institute for Neuroscience and Human Behavior
David Geffen School of MedicineDavid Geffen School of MedicineUniversity of California at Los AngelesUniversity of California at Los Angeles
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NICOTINENICOTINE
Drugs Also Bring Reward (via Dopamine)Drugs Also Bring Reward (via Dopamine)
What have we learned through Positron Emission Tomography (PET)?
Prolonged Changes
In the Brain in Lasting
Ways
“Healthy” Brain
“Cocaine Addict” Brain
Addiction leads to….
BRAIN CHANGESBRAIN CHANGES appear appear prominently in PET scans of prominently in PET scans of current and past drug users current and past drug users
Drug users have far less Drug users have far less dopamine activity (dopamine activity (rightright), as is ), as is indicated by the depletion (dark indicated by the depletion (dark red shows disruption), red shows disruption), compared to the controls compared to the controls (left)(left)
Studies show that this Studies show that this difference contributes todifference contributes to dependence and a diseased dependence and a diseased brainbrain
Behavioral ResponseBehavioral ResponseHow Drugs WorkHow Drugs Work
Loss of controlLoss of control
Continued compulsive Continued compulsive
use despite harmful use despite harmful
consequencesconsequences
Multiple relapses Multiple relapses
preceding stable preceding stable
recoveryrecovery
Partial Recovery of Dopamine Transporters After Prolonged Abstinence
Normal Control Meth user(1 month abstinent)
Meth user(36 months abstinent)
Why is Continued Treatment Why is Continued Treatment Critical?Critical?
Longitudinal Research Support for Addiction as a Chronic
Illness
Advancing the notion of Drug Careers and Treatment Careers….
Landmark study: UCLA ISAP researchers Landmark study: UCLA ISAP researchers (Hser, Anglin et al) followed up a cohort of (Hser, Anglin et al) followed up a cohort of 581 male heroin addicts admitted to the 581 male heroin addicts admitted to the California Civil Addict Program (1962-64) for California Civil Addict Program (1962-64) for over 30 years.over 30 years.
The program was the only major publicly-The program was the only major publicly-funded drug treatment program available in funded drug treatment program available in California in the 60s.California in the 60s.
Tx: combo of inpatient and outpatient drug Tx: combo of inpatient and outpatient drug treatment to narcotic-dependent criminal offenders treatment to narcotic-dependent criminal offenders committed under court order.committed under court order.
Status of Sample atStatus of Sample at 3 Interview Points 3 Interview Points
38%
56%
41%
30%
40%39%
14%
19%
23%
0
20
40
60
1974-75 1985-86 1996-97
Inactive (neg UA) Active (pos UA & refusal) Incarcerated
Natural History of Narcotic Addiction Among SampleNatural History of Narcotic Addiction Among Sample(N=581)(N=581)
Causes of Death Among Sample Causes of Death Among Sample (N = 271)(N = 271)
5
9
10
11
12
28
31
35
56
74
0 10 20 30 40 50 60 70 80
Number of Deaths
Infectious Diseases
Cerebrovascular Disease
Liver Disease (Non-Alcoholic)
Lung/Pulmonary Diseases
Other
Heart Disease
Cancer
Alcohol-Related
Accidents and Violence
Drug-Related
aIncludes overdose, poisoning, drug dependence, and suicide by drugsbIncludes motor vehicle, suicide, firearms, homicide, and fallscIncludes alcoholic cirrhosis, alcohol dependence, and poisoning by alcoholdIncludes kidney disease, diabetes, GI, and epilepsy seizureseIncludes viral hepatitis, AIDS, TB, and staphylococol depticemia
a
b
c
d
e
Implications for the Field
Cannot ignore the chronic nature of Cannot ignore the chronic nature of addiction and the associated long-term addiction and the associated long-term effects of heroin addiction in terms of effects of heroin addiction in terms of morbidity, mortality, criminal justice morbidity, mortality, criminal justice involvement, and overall level of functioninginvolvement, and overall level of functioning
Compared to a US Population sample, Compared to a US Population sample, heroin addiction heroin addiction reducesreduces life expectancy life expectancy by an by an average of 18 yearsaverage of 18 years
Other Long-term Outcome Studies
AlcoholAlcohol: Vaillant et al. conducted multiple long-term : Vaillant et al. conducted multiple long-term follow-up studies with alcoholics (post-tx). Findings follow-up studies with alcoholics (post-tx). Findings repeatedly show that alcoholics experience multiple repeatedly show that alcoholics experience multiple relapses and re-treatments with only 30-50% achieving relapses and re-treatments with only 30-50% achieving stable abstinence.stable abstinence.
Cocaine: Cocaine: Hser et al. 10-yr follow-up study of cocaine Hser et al. 10-yr follow-up study of cocaine users post-tx found that fewer than 50% achieve users post-tx found that fewer than 50% achieve extended periods of abstinence AND most re-enter extended periods of abstinence AND most re-enter treatment multiple times.treatment multiple times.
MethamphetamineMethamphetamine: Marinelli-Casey et al. 3-year follow : Marinelli-Casey et al. 3-year follow up study (600 MA users post-tx) found that 50% up study (600 MA users post-tx) found that 50% continue to use MA at a moderate or severe level continue to use MA at a moderate or severe level throughout the 36 month period. throughout the 36 month period.
Re-Addiction Following PrisonRe-Addiction Following Prison
• Vaillant• 447 opiate addicts 91%
• Maddux & Desmond • 594 opiate addicts 98%
• Nurco & Hanlon • 355 opiate addicts 88%
• Hanlon & Nurco • 237 mixed addicts 70%
Other Studies: Simpson, Wexler, Inciardi, Hubbard, Anglin
Treatment Research Institute
Developing a Treatment System that is Responsive
Given the Research, there has been a Paradigm Shift in Treatment Response…
Focus has increasingly shifted from an acute, model of tx towards a chronic care
model
Shift is been important for adequately understanding and
managing substance use disorders and the recovery process
Are we thereYet?
Are we thereYet?
Public Expectations of Substance Public Expectations of Substance Abuse InterventionsAbuse Interventions
Safe, complete detoxificationSafe, complete detoxification ““The 28 day cure”The 28 day cure” Put them in a box, something happens and they come out Put them in a box, something happens and they come out
fixedfixed The washing machine model: Put a “dirty addict” in, run the The washing machine model: Put a “dirty addict” in, run the
washer, and take out a “clean citizen”washer, and take out a “clean citizen”
Results in:Results in: Reduced use of medical servicesReduced use of medical services Eliminate crimeEliminate crime Return to employmentReturn to employment Eliminate family disruptionEliminate family disruption No return to drug useNo return to drug use
Although, the treatment community is feeling the Shift
We are well trained in the realm of the treatment stages…
Stage of TreatmentStage of Treatment
1. Detoxification
Purpose: Stabilization=Safe/Adequate reduction of withdrawal symptoms -Physical/Emotional stabilization -Promote problem recognition -Engage patient into rehabilitation
Effective Strategies During Effective Strategies During Engagement in RehabilitationEngagement in Rehabilitation
Counseling to Promote Transfer using Counseling to Promote Transfer using NIATx StrategiesNIATx Strategies
These statistics highlight one of the most prominent challenges faced by the addiction treatment field today…
…many people who enter treatment do not complete the necessary course of treatment required for success
Why is this a backward approach?
Much Research Supports the Success of a Chronic Illness Treatment Model
When treated as a chronic illness, the relapse rates of substance dependence are as good or better than other chronic illnesses (McLellan et al., 2005)
So, continuity of care (or client transitions between levels of care) is important for keeping the client engaged in their recovery and preventing relapse
Continuity of care has been shown to be successful in leading to better “long-term” outcomes (compared to acute care):
Abstinence Addiction-related health illnesses Family relationships Legal status Psychiatric issues (including service utilization)
What you (treatment programs) can do to improve these rates?
Given this issue, work with your group & brainstorm about…
Some promising practices for increasing client movement
between levels of care
Strongly encourage client engagement in continued treatment
Actively “hand-off” clients to the other level of care (establish client-counselor linkages)
Be prepared: to bypass barriers Identify what needs to be done (steps) for making the
link (transfer), such as obtaining pre-authorization or what type of transfer paperwork is involved
Address client uncertainty about what to expect Ensure that clients are informed (by alumni or staff)
about the expectations and requirements of the next level of care
Building “connected care” – developing relationships with other levels of care programs…
…This means – sharing clinical (client) information to enable continuity of care
How can you prepare for connected care?
How can you begin to make “connected care” a Reality?
Examine your current processes for collecting and managing clinical (client) information within your program
Consider the ways clinical (client) information can be shared more efficiently (with other programs).
Understand your technology platform -- is it flexible and adaptable enough to support “connected care”
Map your community -- identify addiction stakeholders in your community who your program can collaborate with to build connected care
Start the external communications process – develop some outreach tools that will enable your program to stay connected to referral/transfer sources within the addiction community (in your neighborhood)?
Recovery Services
Treatment/Intervention
Recovery
Telephone Continuing Care
Recovery Coaches/ Centers
Recovery Services
Outpt Tx
Detox
Intensive Otpt Tx
Long-term Res Care
Short-term Res Care
Methadone Maintenance
NTPDetox
What about looking at the % of clients who get…
Recovery Services
Continuing Care
OR
Support Services
What is Continuing Care?
In a chronic care paradigm, it is considered an important level of care for promoting successful
transitions from clinical services to recovery
Types of Continuing Care
Traditional approaches Self/mutual help programs Regular counseling visits
Recovery Check-ups Developed by Researchers from Chestnut Group
(Dennis, Scott et al.) Involves contacting clients every quarter for 2 years
to ask about:• Use of alcohol or drugs on > 2 weeks• Being drunk or high all day on any days• Alcohol/drug use led to not meeting responsibilities• Alcohol/drug use caused other problems• Withdrawal symptoms
…If +++, client referred to linkage manager
Provides: Personalized feedback Explores possibility of returning to treatment Schedules an intake assessment
Telephone based methods
Convenient for client
Reduces stigma of weekly trips to the treatment program
Individualized attention
Can be automated
Lower costs of ongoing care
Measurement Challenges
Currently, we don’t have a method for measuring the extent to which clients are getting continuing care or support services.
What we do know (anecdotally) – it’s grim
Why So Many Clients Don’t Get Continuing Care/Support Services
Program Level
May never get the referral
Logistical/financial disincentives
Resources Views it as the client’s
responsibility
Client Level
- Low motivation - Treatment fatigue
(ready to be finished)
What about Recovery Services?
What is your county currently doing to promote or provide recovery services…
Are we making progress?
Removing Confusion:Removing Confusion:Outcomes vs PerformanceOutcomes vs Performance
Outcomes:Outcomes: OUTCOME MEASURES ARE USED AT OUTCOME MEASURES ARE USED AT THE PATIENT LEVEL AND MEASURE CHANGES IN THE PATIENT LEVEL AND MEASURE CHANGES IN PATIENT BEHAVIOR OR FUNCTIONING OVER TIMEPATIENT BEHAVIOR OR FUNCTIONING OVER TIME
PerformancePerformance: : PERFORMANCE MEASURES ARE PERFORMANCE MEASURES ARE USED AT THE TREATMENT PROGRAM LEVEL TO USED AT THE TREATMENT PROGRAM LEVEL TO EXAMINE THE FUNCTIONING OF THE TREATMENT EXAMINE THE FUNCTIONING OF THE TREATMENT PROGRAMPROGRAM
Treatment Completion is an Treatment Completion is an OUTCOMEOUTCOME
Definition: Per CALOMS discharge, do Definition: Per CALOMS discharge, do people complete treatment people complete treatment
Definitions: Definitions: InitiationInitiation: Do people who enter treatment receive : Do people who enter treatment receive
at least 2 treatment visits in the first 2 weeks?at least 2 treatment visits in the first 2 weeks?Engagement:Engagement: Do people who enter treatment Do people who enter treatment
receive at least 4 sessions in the first 30 days/receive at least 4 sessions in the first 30 days/
Meaningful: YesMeaningful: Yes Clearly Defined: YesClearly Defined: Yes Reliability and Validity of Measures: YesReliability and Validity of Measures: Yes Readily Accessible Data for Measures: ????Readily Accessible Data for Measures: ????
Treatment RetentionTreatment Retention
Definition: Definition: Retention: Number of days between admission Retention: Number of days between admission
and discharge.and discharge.
Meaningful: YesMeaningful: Yes Clearly Defined: YesClearly Defined: Yes Reliability and Validity of Measures: YesReliability and Validity of Measures: Yes
(maybe)(maybe) Readily Accessible Data for Measures: YesReadily Accessible Data for Measures: Yes
Continuity of CareContinuity of Care
Definition: Definition: Do individuals who enter treatment Do individuals who enter treatment
proceed through multiple service sets proceed through multiple service sets (levels of care)(levels of care)
Meaningful: YesMeaningful: Yes Clearly Defined: YesClearly Defined: Yes Reliability and Validity of Measures: YesReliability and Validity of Measures: Yes Readily Accessible Data for Measures: Readily Accessible Data for Measures:
YesYes
System Change Requirements
YES -- $$$
BUT ALSO
Strong Leadership
Motivated staff at all levels
Implementation Team
Infrastructure development (training)
Communication
Collaboration
Patience & Perseverance
Building Interactive Service Building Interactive Service SystemsSystems
To create a treatment system that To create a treatment system that produces the best outcomes for patients,produces the best outcomes for patients,
it is necessary for AOD services within a it is necessary for AOD services within a county to be delivered in a “system of county to be delivered in a “system of care” rather than a “bunch of isolated care” rather than a “bunch of isolated programs”.programs”.
Strategies for improving AOD Strategies for improving AOD program performanceprogram performance
Reduce staff turnoverReduce staff turnover Increase staff knowledge of other forms of Increase staff knowledge of other forms of
care to promote a “system of care” rather care to promote a “system of care” rather than isolated programsthan isolated programs
Increase staff knowledge and use of Increase staff knowledge and use of evidence-based practicesevidence-based practices
Employ process improvement (NIATx)Employ process improvement (NIATx)
